VACCINATIONS IN THE IMMIGRANT CHILD Freddy Karup Pedersen and Anja Poulsen
THE DANISH IMMUNISATION SCHEDULE 3 months Diphteria Tetanus Pertussis Polio-Hib 1- og PCV-1 5 months Diphteria Tetanus Pertussis Polio-Hib 1- og PCV-2 12 months Diphteria-Tetanus-Pertussis-Polio-Hib 3 og PCV-3 15 months MFR 1 4 years MFR 2 5 years Diphteria Tetanus Pertussis Polio revaccination (12 years MFR2) and for girls HPV 1, 2 All women can be vaccinated against rubella for free (Hepatitis B has intermittently been included the last couple of years, depending which DiTePePol vaccine has been udsed)
LOCAL SCHEDULES AND LOCAL SCANDALS http://apps.who.int/immunization_monitoring /globalsummary/schedules Scandals: China: bout two million improperly stored vaccines were sold around the country from an overheated, dilapidated storeroom. The main suspect in the case is a hospital pharmacist from Heze who had been convicted of trading in illegal vaccines in 2009 and was doing it again two years later. The Indonesian government will reinoculate children aged 10 and under after it uncovered fake-vaccine manufacturing and distribution rackets. It is not clear how many children will receive their jabs again, but the number could reach millions.
SSI RECOMMENDATION: UNSURE STATUS OF IMMUNISATION Uge 5a 2015 EPINYT Complicated!!! Børn under 5 år: Ved usikre oplysninger om tidligere vaccinationer begyndes forfra med samme interval som i det danske børnevaccinationsprogram, dvs. to måneder (mindst én måned) mellem 1. og 2. vaccination og syv måneder (mindst seks måneder) mellem 2. og 3. vaccination. Ved kraftige lokalreaktioner anbefales det at måle antistoffer mod difteri og tetanus én måned efter vaccination. Børn på 5-9 år: For at undersøge om barnet er tilstrækkeligt primærvaccineret, gives en Di-Te-Ki-Pol/Hib-primærvaccine (DiTeKiPol/Act- Hib), og efter én måned måles antistoffer mod difteri og tetanus. (Hvis barnet er fyldt 6 år, kan Hib-komponenten udelades, se senere). Ved antistofniveau < 0,1 IE/ml for enten difteri eller stivkrampe kan man ikke regne med, at barnet er primærvaccineret. Det anbefales da at give yderligere to Di-Te-Ki-Pol-primærvacciner med de anførte minimumsintervaller. Revaccination med di-teki-pol-vaccine (DiTeKiPol Booster) gives 4-5 år efter sidste primærvaccine. Ved antistofniveau >= 0,1 IE/ml for både difteri og stivkrampe er barnet formentlig primærvaccineret. Beskyttelsens varighed vil da afhænge af antistofniveauet. Ved efterfølgende vaccination anvendes di-te-ki-pol-vaccine til revaccination. Børn på 10-17 år: For at undersøge om barnet er tilstrækkeligt primærvaccineret, gives en di-te-ki-pol-vaccine til revaccination, og efter én måned måles antistoffer mod difteri og tetanus.
SYRIA Refugee from Syria - 4 years old The mother says she has received all vaccinations before they left Syria. She has no vaccination card What to do?
REFUGEE LOCAL SCHEDULE Often no vaccination card www.folkhalsomyndigheten.se/.../vaccin-till-manniskor-pa-flykt-nya-rekommendationer
SYRIA COVERAGE www.folkhalsomyndigheten.se/.../vaccin-till-manniskor-pa-flykt-nya-rekommendationer
WHAT TO DO? 1. Start the vaccination program from scratch the vaccines were probably not optimal due to problems with the cold chain - and without a vaccination card you cannot be sure about the vaccinations 2. Measure antibodies to tetanus and measles as an indicator of vaccination status if OK consider the child as vaccinated 3. Give a booster DiTeKiPol Act Hib and an extra MFR. Then you can be quite sure the child is vaccinated. 4. Give a booster DiTeKiPol and measure antibodies 5. She is better immunized than Danish children everything is OK now 6. Let the GP decide
UNSURE HISTORY? Mothers story to trust? Do you always need a vaccination card? If the mother is well-educated and can tell about the conditions of the immunisations, still unsure?
UNSURE INFORMATIONS If the information is unsure? SSI: Unsure information - start with same interval as the Danish child immunisation Schedule. If severe local reactions measure antibodies against Diphteria and Tetanus one month after vaccination. Are other approaches possible? Measure antibodies when the child is seen first time in connection with screening for infectious diseases (TB). Is more better?? Adverse events (Granulomas? Allergy to aluminium? Other local reactions? Other AEs? Non specific effects?) Immuneresponse might not be better More injections can be traumatic
WHAT TO DO? 1. Start the vaccination program from scratch the vaccines were probably not optimal due to problems with the cold chain - and without a vaccination card you cannot be sure about the vaccinations- the vaccines were probably OK 2. Measure antibodies to tetanus (Diphteria) and measles as an indicator of vaccination status if OK consider the child as vaccinated possible solution if blood samples today - it gives sense 3. Give a booster DiTeKiPol Act Hib and an extra MFR. Then you can be quite sure the child is vaccinated. Maybe too much or maybe not enough 4. Give a booster DiTeKiPol and measure antibodies possible solution - SSI recommendation 5. She is better immunized than Danish children everything is OK now better immunized but there might have been problems with storage. 6. Let the GP decide- the easiest
WHAT DO WE KNOW OF UPTAKE OF IMMUNISATIONS AMONG REFUGEE CHILDREN IN DENMAK Marie Nørredam et al (2016, Eur J Pediatr 175:539-549): What is Known: Uptake of immunisation and child health examination is associated with low household income, unemployment and low educational status among the parents. Uptake may be even lower among refugee families as they constitute a vulnerable group regarding access to healthcare. What is New: Refugee children had lower uptake of immunisations and child health examinations compared to Danish-born children for DTP 5 years old (relative HR 0,61 for refugees) Several predictors of uptake were identified including region of origin and duration of residence.
MARIE NØRREDAM ET AL 2016: Promote immunisation and Child Health Examinations among newly arrived refugee families
ADOPTED CHILD Often Information of immunisation Often vaccination card Highly motivated parents Focus on avoiding unnecessary injections/blood samples
ADOPTED CHILDREN Know about the program of the country of origin. Written records may considered valid if the vaccines, dates etc is OK Documentation improves the likelihood for seroconversion from for example for Tetanus to 95% from 76% for Tetanus (Staat MA et al Vaccine 2010;28(50):7947-55). Defiecient immunization in 37% of adoptees (Jenista and Chapman: Medical problems of foreign-born adopted children Am J Dis Child 1987; 141:298-302) - depending on origin. Serological testing for (Diphteria) and Tetanus can be used as surrogate marker for pertussis. Often MMR is not included - but only Measles vaccine booster with MMR. Catch up program appropiate for age If not given Hib and PV - consider vaccination
DATES MIGHT BE CONFUSING
CONCLUSION Recommendations in EPINYT Use common sense to evaluate parents history of vaccination Measure antibodies if necessary Know the local vaccination schedule and local problems Consider MMR booster, Hib and PV